The Extended Deltoid-Splitting Approach to the Proximal Humerus

Abstract

The recent technological developments in implant design and the wider availability of bone graft substitutes have stimulated a renaissance in the operative treatment of complex proximal humeral fractures. However, one of the remaining problems of the operative treatment of these injuries has been the limited surgical access to the posterior aspect of the shoulder afforded by the deltopectoral approach. In this article, we describe a novel extended deltoid-splitting approach, in which the area traversed by the axillary nerve is identified and protected during the surgery. We feel that this approach provides enhanced surgical exposure and offers a useful alternative to the deltopectoral approach in the operative treatment of 3- and 4-part proximal humeral fractures.

Minimally invasive plate osteosynthesis with a locking compression plate is superior to open reduction and internal fixation in the management of the proximal humerus fractures

“…The deltopectoral approach requires extensive soft tissue dissection and muscle retraction to gain adequate exposure to the lateral aspect of the humerus [10,11,14,16,18-20]. This can cause further devascularization of fracture fragments during dissection and plating, leading to the disruption of critical blood supplies to the humeral head [10,18-20].…”

“…This can cause further devascularization of fracture fragments during dissection and plating, leading to the disruption of critical blood supplies to the humeral head [10,18-20]. The deltoid splitting approach, which is an alternative method, provides good visualization of the posterolateral aspect of the shoulder without extensive soft tissue dissection or forcible retraction; however, there is an increased risk of injuring the axillar nerve as compared to the conventional deltopectoral approach [16,21,22]. Recently, many studies have demonstrated the superiority of MIPO techniques via anterolateral deltoid splitting combined with skin incisions for the management of proximal humerus fractures [15,17,19,21-28].…”

“…This method is a minimally invasive technique, leading to less soft tissue injury, decreased postoperative pain, and decreased functional loss. In addition, MIPO allows for the visualization of the axillary nerve [12,14,16,22]. Thus, MIPO is a safe and effective method for the treatment of proximal humerus fractures [14,19,20,22].…”

Proximal humerus fractures with valgus deformity of the humeral head: The spectrum of injury, clinical assessment and treatment

“…This approach improves access to fracture fragments, facilitates optimal plate positioning, and may help to preserve any remaining blood supply 18,43 to the proximal humerus. Detailed knowledge of the course of the anterior branch of the axillary nerve is required to minimize risk of damage during this approach.…”

“…More recently, an extended deltoid splitting approach has been described, using either a straight lateral 12,16,17 or shoulder strap 43,45,46 skin incision, with careful protection of the anterior branch of the axillary nerve. This approach improves access to fracture fragments, facilitates optimal plate positioning, and may help to preserve any remaining blood supply 18,43 to the proximal humerus.…”